Infant formula advertising

Does infant formula provide the benefits advertisers claim?

The infant formula industry spends a lot on advertising, trying to convince parents to buy certain brands. Advertising is aimed not only at families, but at health-care providers and their organizations, hospitals, and governments. In the process, it undermines breastfeeding. Many advertising campaigns claim that products are “closer to breast milk” than competitors’ products. Companies make “improvements” to products to gain an advantage over competitors or to justify higher prices. However, the findings of independent research often differ widely from the advertising claims. Companies have claimed, for example, that certain infant formula reduces colic and gas or decreases the risk of allergic disease. Other ads claim benefits from the addition of certain fats or prebiotics and probiotics. Research supporting them is limited and in some cases funded by infant formula makers.

A) Describing the marketing of infant formula

Infant formula (formula) has improved through the 20th century. During this time, formula manufacturers also evolved to where the formula market is now controlled by six of the most powerful food companies in the world, with massive household and global reach. It was worth about USD 70 billion in 2019 (WHO 2020). These companies aim to increase shareholder value through the sale of formula. Profit (income after expenses) on formula sales is about 23%, making it a high-margin product along with pet food and premium coffee (Hastings 2020).

Companies use marketing to differentiate their products from those of competitors and to increase sales (Munblit 2020). For example, marketing has been very successful at creating a demand for toddler milk, a product deemed unnecessary by many health organizations.

Marketing practices for formula have been a long-standing concern as they decrease the initiation of breastfeeding, the likelihood of exclusive breastfeeding, and the duration of breastfeeding (Parry 2013; Kaplan 2008; Piwoz 2015; Rosenberg 2008; Sadacharan 2014; Stevens 2009; Waite 2016). 

The World Health Organization notes that (WHO 2020):

“Aggressive and inappropriate marketing of breast-milk substitutes, and other food products that compete with breastfeeding, continues to undermine efforts to improve breastfeeding rates. Such marketing practices often negatively affect the choice and ability of mothers to breastfeed their infants optimally.”

Marketing of formula is extensive. One report by Save the Children (STC 2018) indicates that formula companies may have spent as much as USD 7.2 billion on advertising and marketing in 2015. If spending on sales staff and administration is included, the amount increases to USD 17 billion, or about one-quarter of the value of global sales.

B) Marketing practices of the infant formula industry

While the ultimate target of the marketing are families, who decide how their babies are fed, marketing targets them directly and indirectly (Brady 2012). 

1) Families 

Families are directly targeted in numerous ways (Hastings 2020; Vinje 2017):

  • Baby clubs which claim to offer information and support. These aim to increase brand loyalty and allow companies to collect personal data which is used to streamline further marketing.
  • Advertising of formula, bottles, and bottle nipples (Mason 2018; Silva 2020; Smith 2013) in conventional media, on websites, through social media, and on apps (Pomeranz 2021; Zhao 2019).
  • In-store special displays and discounts (de Oliveira 2020)
  • Gift bags and pacifiers from hospitals (Morain 2018; Sadacharan 2014; Schliep 2019).
  • Promotional items such as formula samples and discount coupons sent to them directly or received from their health-care providers (Dusdieker 2006; Howard 2000).
  • Other promotional items such as diaper bags, change pads, and toys.

Formula marketing approaches include (Hastings 2020):

  • The “soft sell”
  • Building false friendships
  • Stressing its similarity to breast milk

2) Pharmacies and pharmacists 

Pharmacies and pharmacists stand to gain directly from sales of formula. Examples of marketing undertaken by pharmacies aimed at families include (Funduluka 2018; Hadihardjono 2019):

  • Joint promotion with infant foods such as snacks or other baby-themed items (Prado 2020)
  • Advertising of formula, bottles, nipples, and related products
  • Promotional items such as formula samples and discount coupons
  • Images and labels which idealize formula-feeding and lack breastfeeding information

3) Doctors and other health-care providers 

Doctors and other health-care providers have an important role in the decisions made by families. Formula manufacturers can benefit if providers have a positive opinion of their products. Marketing to health-care providers includes the following (Greer 1991; Howard 1993; Lake 2019; Taylor 1998; Wright 2006):

  • Gifts and free meals and travel
  • Research or scholarship grants
  • Promotional office supplies such as weight-scale liners
  • Payment for industry-prepared talks to parents and other health-care providers 
  • Visits from company representatives promoting formula
  • Advertising posters, free samples, and discount coupons

Nurses (milk nurses) and sales representatives claiming to be nurses have been employed by formula companies to promote their products (Brady 2012; Lakani 1984). 

4) Doctors’ organizations 

One study (Grummer-Strawn 2019) in 2019 showed that 60% of 114 national pediatric associations accepted funding from formula companies. Funding is used for the following (Bognar 2020; Greer 1991; Thornton 2016; Sharfstein 2017):

  • Direct sponsorship of the organization
  • Educational grants
  • Support of conferences and other events
  • Purchasing of advertising in organization journals (Hickman 2021)
  • Funding of newsletters or other publications
  • Funding of awards

Again, these are designed to ensure providers have a positive opinion of their products.

5) Research

Research may be funded by formula manufacturers or done directly by the manufacturer and has been shown to lack independence or transparency, and published outcomes are biased by selective reporting (Helfer 2021; Tanrikulu 2020).

Medical journals that publish studies may accept advertising revenue from manufacturers (van Tulleken 2018).   

6) Hospitals and government agencies 

Hospitals and governmental agencies may have a close association with formula manufacturers (Kent 2006). Manufacturers may provide: 

  • Items labelled with the formula brand or promotional advertising:
    • Free or low-cost formula, sterile water
    • Free or low-cost bottles, bottle nipples, and pacifiers
    • Crib (cot) cards, measuring tapes, and change pads
  • Hospital equipment such as incubators (baby isolettes)
  • Meals and marketing events often described as educational sessions for staff
  • Grants of money
  • Funding to members of committees or boards that create guidelines and policies (van Tulleken 2018)

7) Government officials and politicians

Formula manufacturers lobby government officials and politicians (Tanrikulu 2020; Khazan 2018). 

C) The World Health Organization Code of Marketing of Breast-milk Substitutes

The World Health Organization Code of Marketing of Breast-milk Substitutes (the Code) was established in 1981 and aims to curb the promotion of formula (WHO 1981). There have been many subsequent resolutions.

The main points are:

  1. No advertising of formula or other breast milk substitutes to the public.
  2. No free samples to mothers, their families, or health workers.
  3. No promotion of products in the health-care system through displays, posters, or distribution of promotional materials. No use by health-care systems of personnel provided by formula companies.
  4. No gifts or samples to health workers. Product information must be factual and scientific. No free or low-cost supplies of breast milk substitutes to any part of the health-care system.
  5. Information and educational materials must explain the benefits of breastfeeding, the health hazards of bottle-feeding, and the costs of using formula.
  6. Product labels must clearly state the superiority of breastfeeding, the need for the advice of a health worker and a warning about health hazards. No pictures of babies or other pictures or text idealizing the use of formula.
  7. Unsuitable products, such as sweetened condensed milk, should not be promoted for babies. All products should be of high quality, have expiration dates, and take account of the climate and storage conditions of the country where they are used.

The implementation of the Code needs political will and transparent governing structures (Forsyth 2013). As of April 2018, only 136 of 194 countries had legal measures enforcing provisions of the Code (WHO 2020). Of these, 25 countries had measures substantially aligned with the Code, and a further 42 had measures that are moderately aligned.

Countries with no legal measures include Angola, Argentina, Australia, Belarus, Canada, Central African Republic, Cuba, Eritrea, Japan, Lesotho, Libya, Malaysia, Mauritania, Morocco, Namibia, New Zealand, North Korea, Sierra Leone, Somalia, South Sudan, and the United States (WHO 2020).

As a result, there are often few restrictions in these countries on how formula companies operate (Harris 2020). Information given to parents may be:

  • Confusing (Berry 2011; Periera 2016).
  • Biased and not supported by independent research (Kent 2014; Koletzko 2006).
  • Misleading (Changing Markets Foundation 2018; Kean 2014).
  • Poorly regulated (Wallingford 2018).

Additionally, where there are legal measures, they may not be enforced (Berry 2017; Liu 2014; Prado 2020).

D) Types of advertising claims by infant formula manufacturers

1) Claims of being “closer to breast milk”

Infant formula is fundamentally different from breast milk but many advertising campaigns claim that their products are “closer to breast milk” than the competitors’ products. 

“Improvements” in the products are made to gain an advantage over a competitor or to justify higher prices. However, the findings of independent research often differ widely from the claims made by formula companies (Belamarich 2016; Braegger 2011; Jasani 2017; Moon 2016; Mugambi 2012; Verner 2007). 

2) Claims of reduction of gas and colic

Manufacturers make unjustified claims that their products reduce colic and gas. One study (Belamarich 2016) examined 22 examples of formula advertising in the U.S. Thirteen included such claims. There is not enough evidence to support these claims (Gordon 2018).

Manufacturers of “low gas” formula brands may replace the normal milk sugar, lactose, with other sugars that may be less healthy. Examples include corn syrup solids or table sugar; interestingly both are banned in regular European formula.

3) Claims of benefits from lactose-free and lactose-reduced formula

Some advertising campaigns have promoted lactose-free or lactose-reduced formula. However, it is very rare for a baby not to be able to digest lactose. It is the main sugar in breast milk. As with low gas formula, lactose-free formula will use other sugars that may be less healthy. 

4) Claims of benefits from DHA, ARA, omega-3, and long-chain polyunsaturated fatty acids

Formula companies continue to advertise the benefits of certain fats known as long-chain polyunsaturated fatty acids (LCPUFAs). These include omega-3 fats such as docosahexaenoic acid (DHA) and alpha-linolenic acid (ALA) and omega-6 fats such as arachidonic acid (ARA). These are now found in most infant formula.

Most DHA used in formula is extracted from the algae Crypthecodinium, Schizochytrium, and Ulkenia using solvents such as hexane, acid, and bleach (Kent 2014; Zou 2016). ARA is usually obtained from oil made of the fungus Mortierella alpina. The chemical structure of DHA and ARA is different from the DHA and ARA found naturally in breast milk (Kent 2014).  

The quality of the research on the effect of adding LCPUFAs is low and the long-term effect of adding these to formula remains uncertain (Jasani 2017; Verfuerden 2020). Adding DHA to infant formula has shown inconsistent results in premature babies (Keim 2018; Smith 2017). 

5) Claims of benefits from pre- and probiotics

i) Prebiotics

A prebiotic is an agent,  often  a type of sugar, that helps good bacteria grow. Think of prebiotics as fertilizer for good bacteria.

Breast milk contains large amounts and varieties of specialized sugars (human milk oligosaccharides [HMOs]) that cannot be digested by the baby. Rather these are consumed by helpful bacteria in the gut which prevents the over-growth of harmful ones. HMOs are an example of a prebiotic.

HMOs not only prevent infection in the gut and elsewhere but also support the development of a normal immune system and provide nutrients for growth.

There are over 200 types of HMOs and the types of HMOs vary between mothers and are present in large amounts in breast milk.

Some formula companies add one or several HMOs to formula. Examples include 2'fucosyllactose (2'FL) and lacto-N-neotetraose (LNnT). These appear to be safe for babies (Puccio 2017) however, their long-term effects are unknown. Breast milk has many more varieties of HMOs and they are more complex and present in larger amounts (Ayechu-Muruzabal 2018; Nijman 2018).

ii) Probiotics

A  probiotic  is a type of organism,  usually a bacteria, usually given to people to treat or prevent disease by improving the health of the microbiome, the microorganisms in the body. Bifidobacterium and Lactobacillus species are probiotics that have been added to formula.

If formula is powdered and the baby is under four months, the formula should be prepared with water that has been boiled and cooled to 70° Celsius (160° Fahrenheit). This is needed to kill dangerous bacteria (cronobacter) that may be present in the powder, but it also kills the probiotics, so their presence in powdered formula is irrelevant for babies less than four months of age.

iii) Evidence for benefits of pre- and probiotics in formula

Formula manufacturers have added pre- and probiotics to formula and have claimed they improve the baby’s gut microbiome and health. However, the evidence is limited (Bode 2018; Cuello-Garcia 2016; Mugambi 2012; Plaza-Díaz 2018; Shahramian 2018; Skórka 2017; Skórka 2018).

Probiotics do not appear to decrease crying in infant formula-fed babies (Sung 2013; Sung 2018).

Indeed, a number of groups have found there is insufficient data to recommend the routine use of formulas supplemented with pre- or probiotics. These include:

  • The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHN) (Braegger 2011)
  • The European Union (EFSA 2014)
  • The American Academy of Pediatrics (Thomas 2010)

The ESPGHN noted that most studies of the benefits of adding pre- and probiotics to formula were funded by the companies that produced the formula (Braegger 2011). Similar concerns were raised by other researchers (Mugambi 2014). 

The addition of HMOs is often used to justify a significant increase in price.

6) Claims of reduction of allergic diseases and type 1 diabetes

a) Allergic diseases

There is insufficient evidence that any of the following can prevent allergic diseases (asthma, eczema, hay fever, food allergies) when given during pregnancy, breastfeeding, or early life (Vandenplas 2020):

  • Omega-3 LCPUFA (including DHA)
  • Prebiotics
  • Probiotics

There is insufficient evidence that partially or extensively hydrolyzed infant formula can prevent allergic diseases (EFSA 2021; Greer 2019; Osborn 2018; Vandenplas 2020).

b) Type 1 diabetes

Extensively hydrolyzed formula does not decrease the risk of type 1 diabetes in babies at risk (Boyle 2016; Writing Group for the TRIGR Study Group 2018).

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